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A few years ago,

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I was taking care of a woman
who was a victim of violence.

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I wanted her to be seen in a clinic
that specialized in trauma survivors.

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I made the appointment myself because,
being the director of the department,

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I knew if I did it,

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she would get an appointment right away.

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The clinic was about an hour and a half
away from where she lived,

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but she took down the address
and agreed to go.

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Unfortunately, she didn't
make it to the clinic.

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When I spoke to the psychiatrist,

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he explained to me

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that trauma survivors are often resistant

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to dealing with the difficult
issues that they face,

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and often miss appointments.

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For this reason,

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they don't generally allow the doctors
to make appointments for the patients.

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They had made a special exception for me.

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When I spoke to my patient,

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she had a much simpler
and less Freudian explanation

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of why she didn't go to that appointment:

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her ride didn't show.

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Now, some of you may be thinking,

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"Didn't she have some other way
of getting to that clinic appointment?"

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Couldn't she have taken an Uber

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or called another friend?

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If you're thinking that,

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it's probably because you have resources.

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But she didn't have
enough money for an Uber,

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she didn't have another friend to call.

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But she did have me, and I was able
to get her another appointment,

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which she kept without difficulty.

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She wasn't resistant,
it's just her ride didn't show.

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I wish I could say that this
was an isolated incident,

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but I know from running
the safety net systems

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in San Francisco, Los Angeles,
and now New York City,

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that health care is built
on a middle class model

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that often doesn't meet the needs
of low-income patients.

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That's one of the reasons why
it's been so difficult

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for us to close
the disparity in health care

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that exists along economy lines

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despite the expansion of health insurance

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under the ACA, or ObamaCare.

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Health care in the United States

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assumes that, besides getting across
the large land expanse of Los Angeles,

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it also assumes that you
can take off from work

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in the middle of the day to get care.

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One of the patients who came
to my East Los Angeles clinic

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on a Thursday afternoon

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presented with partial blindness

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in both eyes.

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Very concerned, I said to him,

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"When did this develop?"

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He said, "Sunday."

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I said, "Sunday?

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Did you think of coming sooner to clinic?"

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And he said, "Well, I have to work
in order to pay the rent."

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A second patient to that same clinic,

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a trucker,

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drove three days with a raging infection,

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only coming to see me
after he had delivered his merchandise.

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Both patients' care was jeopardized
by their delays in seeking care.

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Health care in the United States
assumes that you speak English

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or can bring someone with you who can.

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In San Francisco, I took care of a patient
on the inpatient service

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who was from West Africa

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and spoke a dialect so unusual

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that we could only find one translator
on the telephonic line

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who could understand him,

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and that translator only worked
one afternoon a week.

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Unfortunately, my patient
needed translation services every day.

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Health care in the United States
assumes that you are literate.

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I learned that a patient of mine
who spoke English without accent

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was illiterate

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when he asked me to please sign
a social security disability form

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for him right away.

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The form need to go
to the office that same day,

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and I wasn't in clinic,

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so trying to help him out,

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knowing that he was
the sole caretaker of his son,

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I said, "Well, bring the form
to my administrative office.

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I'll sign it and I'll fax it in for you."

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He took the two buses to my office,

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dropped off the form,

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went back home to take care of his son,

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I got to the office, and what did I find
next to the big "X" on the form?

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The word "applicant."

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He needed to sign the form.

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And so now I had to have him
take the two buses back to the office

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and sign the form so that
we could then fax it in for him.

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It completely changed
how I took care of him.

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I made sure that I always went over
instructions verbally with him.

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It also made me think about
all of the patients

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who receive reams and reams of paper

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spit out by our modern
electronic health record systems

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explaining their diagnoses
and their treatments,

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and wondering how many people actually

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can understand what's on
those pieces of paper.

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Health care in the United States assumes
that you have a working telephone

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and an accurate address.

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The proliferation
of inexpensive cell phones

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has actually helped quite a lot,

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but still my patients run out of minutes

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and their phones get disconnected.

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Low-income people often have
to move around a lot by necessity.

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I remember reviewing a chart of a woman
with an abnormality on her mammogram.

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That chart assiduously documents
that three letters were sent to her home

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asking her to please come in for followup.

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Of course, if the address isn't accurate,

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it doesn't much matter how many letters
you send to that same address.

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Health care in the United States assumes
that you have a steady supply of food.

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This is particularly
an issue for diabetics.

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We give them medications
that lower their blood sugar.

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On days when they don't have enough food,

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it puts them at risk
for a life-threatening side effect

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of hypoglycemia, or low blood sugar.

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Health care in the United States assumes
that you have a home

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with a refrigerator for your insulin,

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a bathroom where you can wash up,

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a bed where you can sleep
without worrying about violence

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while you are resting.

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But what if you don't have that?

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What if you live on the streets,

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you live under the freeway,

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you live in a congregant shelter

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where every morning
you have to leave at 7 or 8 am?

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Where do you store your medicines?

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Where do you use the bathroom?

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How do you put your legs up
if you have congestive heart failure?

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Is it any wonder that providing people
with health insurance who are homeless

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does not erase the huge disparity

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between the homeless and the housed?

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Health care in the United States assumes
that you prioritize your health care,

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but what about all of you?

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Let me assume for a moment
that you're all taking a medication.

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Maybe it's for high blood pressure.

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Maybe it's for diabetes or depression.

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What if tonight you had a choice:

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you could have your medication
but live on the street,

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or you could be housed in your home
but not have your medication?

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Which would you choose?

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I know which one I would choose.

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This is just a graphic example
of the kinds of choices

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that low-income patients
have to make every day.

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So when my doctors
shake their heads and say,

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"I don't know why that patient
didn't keep his followup appointments,"

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"I don't know why she didn't go
for that exam that I ordered,"

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I think, well, maybe her ride didn't show,

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or maybe he had to work.

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But also, maybe there was something
more important that day

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than their high blood pressure
or a screening colonoscopy.

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Maybe that patient was dealing
with an abusive spouse

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or a daughter who is pregnant
and drug-addicted,

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or a son who was kicked out of school,

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or even maybe they were riding
their bicycle through an intersection

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and got hit by a truck,

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and now they're using a wheelchair
and have very limited mobility.

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Obviously, these things also happen
to middle class people,

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but when they do,

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we have resources that enable us
to deal with these problems.

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We also have the belief that we
will live out our normal lifespans.

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That's not true for low-income people.

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They've seen their friends and relatives
die young of accidents, of violence,

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of cancers that should have
been diagnosed at an earlier stage.

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It can lead to a sense of hopelessness,

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that it doesn't really matter what you do.

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I know I've painted a bleak picture
of the care of low-income patients,

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but I want you to know
how rewarding I find it

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to work in a safety net system

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and my deep belief that we
can make the system responsive

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to the needs of low-income patients.

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The starting point has to be
to meet patients where they are,

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provide services without obstacles,

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and provide patients what they need,

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not what we think they need.

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It's impossible for me
to take good care of a patient

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who is homeless and living on the street.

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The right prescription
for a homeless patient is housing.

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In Los Angeles, we have 4,700
chronically homeless persons

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suffering from medical illness,

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mental illness, addiction.

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When we house them, we found
that overall health care costs,

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including the housing, decreased.

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That's because they had
many fewer hospital visits,

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both in the emergency room
and on the inpatient service.

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And we gave them back their dignity.

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No extra charge for that.

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For people who do not have
a steady supply of food,

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especially those who are diabetic,

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safety net systems are experimenting
with a variety of solutions,

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including food pantries
at primary care clinics,

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distributing maps of community
food banks and soup kitchens.

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And in New York City,

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we've hired a bunch of enrollers

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to get our patients

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into the supplemental nutrition program
known as food stamps to most people.

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When patients and doctors
don't understand each other,

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mistakes will occur.

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For non-English-speaking patients,
translation is as important

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as a prescription pad,
perhaps more important.

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And, you know, it doesn't
cost anything more

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to put all of the materials
at the level of fourth-grade reading

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so that everybody can understand
what's being said.

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But more than anything else,
I think low-income patients

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benefit from having a primary care doctor.

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Mind you, I think middle class people
also benefit from having somebody

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to quarterback their care,

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but when they don't, they have others
who can advocate for them,

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who can get them that disability placard,

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or make sure the disability
application is completed.

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But low-income people really need
a team of people who can help them

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to access the medical and non-medical
services that they need.

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Also, many low-income people
are disenfranchised

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from other community supports,

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and they really benefit from the care
and continuity provided by primary care.

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A primary care doctor
I particularly admire

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once told me how she believed
that her relationship with a patient

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over a decade was the only 
healthy relationship

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that that patient had in her life.

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The good news is, you don't
actually have to be a doctor

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to provide that special sauce
of care and continuity.

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This was really brought home to me
when one of my own long-term patients

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died at an outside hospital.

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I had to tell the other doctors
and nurses in my clinic

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that he had passed.

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But I didn't know that
in another part of our clinic,

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on a different floor,

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there was a registration clerk

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who had developed
a very special relationship

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with my patient every time
he came in for an appointment.

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When she learned three weeks later
that he had died,

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she came and found me
in my examining room,

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tears streaming down her cheeks,

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talking about my patient

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and the memories that she had of him,

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the kinds of discussions that they had had
about their lives together.

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My patient had a hard life.

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He was by his own admission a gangbanger.

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He had spent substantial
amount of time in prison.

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He suffered from a very serious illness.

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He was a drug addict.

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But despite all that,
he rarely missed a visit,

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and I like to believe that was because
he knew at our clinic that he was loved.

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When our health care systems have the same
commitment to low-income patients

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that that man had to us,

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two things will happen.

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First, the system will be responsive
to the needs of low-income people.

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It will speak their language,
it will meet their schedules,

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it will fulfill their needs.

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Second, we will be providing
the kind of care

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that we went into this profession to do,

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not just checking the boxes

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but really taking care of those we serve.

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00:15:41,619 --> 00:15:44,945
Thank you.

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(Applause)